A 73-year-old man with congestion and mild …tosis and resolved conjunctival chemotic congestion of left eye. C, Moderate restriction of elevation in left eye. other orbital metastases

Grand RoundsA 73-year-old man with congestion and mild proptosis of the left eyeAmanda Mohanan-Earatt, MS, Lathika Vasu Kamaladevi, MS, DO, FRCS (Glasgow), and CharlesK. Skariah, MS, DOAuthor affiliations: Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India

HistoryA 73-year-old man presented to the Department of Oph-thalmology, Amala Institute of Medical Sciences, Ker-ala, with mild congestion of left eye. He believed thathis symptoms began after accidental exposure of hiseyes to medicated oil used during a massage session, aspart of traditional medical treatment he was taking. Hewas diagnosed with toxic conjunctivitis and treated withloteprednol eyedrops. At his follow-up visit on the thirdday, he complained that his left eye had not improvedand that it was starting to “bulge out.”

The patient denied vision loss, double vision, headache,or other systemic symptoms. He had undergone bilateralorchidectomy and radiotherapy for prostate carcinoma 3years earlier and was now on hormone therapy withbicalutamide. He had undergone thyroidectomy forhyperthyroidism 15 years previously and was now onle-vothyroxine. Ocular history was remarkable for unevent-ful cataract extraction in both eyes with IOL placement20 years previously.

ExaminationOn initial examination, best-corrected visual acuity was20/20 in each eye. Color vision was normal in both eyes.There was periorbital fullness and partial ptosis of theleft eye. Palpation revealed apainless, firm swellingalong the lateral one-third of superior orbital margin. Itwas found to displace the globe inferiorly (Figure 1A).Hertel exophthalmometry measured 16 mm in the righteye and 22 mm in the left eye (Figure 1B). Ocular motil-ity was full on the right side; the left eye showed gener-alized restriction and complete loss of elevation (Figure1C).Slit-lamp examination of the anterior and posteriorsegments was entirely normal except for temporal bulbar

conjunctival congestion with chemosis in left eye. Pupilswere reactive, with no afferent pupillary defect.

General examination did not reveal any abnormal cervi-cal lymph nodes. Cranial nerve evaluation was withinnormal limits.

Ancillary TestingRoutine blood testing, thyroid function tests, and pros-tate specific antigen (PSA; 0.1 ng/ml) were within nor-mal limits. Computed tomography (CT) of brain andorbit demonstrated an enhancing lytic lesion, with a sig-nificant soft tissue component and calcification. It meas-ured 22 × 35 × 34 mm and involved the left frontal boneencroaching on the lateral wall of orbit. The lesion wasfound to indent the globe on its superior aspect. Both thesuperior rectus and superior oblique muscles appeared tobe involved. The left optic nerve was free. These find-ings were suggestive of left orbital metastasis with intra-cranial extension (Figure 2).

Figure 1. Clinical photograph of the patient at presentation. A,Left periorbital fullness and partial ptosis, with inferior displace-ment of the globe. B, Proptosis of left eye with temporal conjuncti-val congestion and chemosis. C, Complete loss of elevation in lefteye.

Published April 25, 2016.Copyright ©2016. All rights reserved. Reproduction in whole or in part in any form or medium without expressed written permission of theDigital Journal of Ophthalmology is prohibited.doi:10.5693/djo.03.2014.05.001Correspondence: Amanda Mohanan Earatt, Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India (email:[email protected]).

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Fine-needle aspiration cytology of the mass was under-taken and a diagnosis of poorly differentiated carci-noma, possibly adenocarcinoma was made (Figure 3).PSA staining confirmed prostatic origin.

TreatmentThe patient was referred to an oncologist for treatment.He underwent metastatic evaluation with bone scintigra-

Figure 2. Computed tomography of the brain and orbits. Axialimages (A, soft tissue window; B, bone window) showing enhanc-ing lytic lesion (22 × 35 × 34 mm), with significant soft tissuecomponent and calcification. Coronal reconstruction (C) showingthe lesion eroding left frontal bone on the lateral wall of the orbit.

Figure 3. Fine-needle aspiration cytology showing round to pol-ygonal cells having hyperchromatic pleomorphic nuclei, withindistinct nucleoli and moderate amount of eosinophilic cytoplasm(black arrow); scattered bare nuclei (red arrow) were also noted (H& E, original magnification ×40, ×100, ×400).

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phy and contrast enhanced CT of the thorax, abdomen,and pelvis. No other foci of metastasis were identified,and he subsequently underwent palliative conformalradiotherapy to left orbit (total dose, 30Gy/10#).Twoweeks after radiotherapy, the left eye showed madarosiswith partial ptosis (Figure 4A). The lid edema and prop-tosis were significantly reduced compared to the previ-ous visit. The conjunctival chemosis and congestion hadresolved completely (Figure 4B). Extraocular move-ments had improved, but moderate restriction of eleva-tion persisted (Figure 4C).

Differential DiagnosisIn this patient, the differential diagnosis included a lacri-mal gland tumor or idiopathic orbital inflammation,which are the most common lesions in the lacrimalgland area. A history of thyroid disorder, with clinicalsigns of unilateral proptosis, restricted ocular motility,and the presence of temporal flare and chemosis of theconjunctiva, prompted us to include thyroid ophthalm-opathy in the differential diagnosis. The possibility ofprimary or metastatic orbital tumors was also consideredin view of the patient’s history of prostate carcinoma.

Diagnosis and DiscussionThe patient was diagnosed with left orbital metastasisfrom adenocarcinoma of the prostate with intracranialextension. About 2%–9% of all orbital neoplasms aremetastatic lesions.1 Breast, lung, lymphomas, and leuke-mia are among the most common primary neoplasmsknown tometastasize to the orbit.2,3 The average age ofonset of orbital metastasis from prostate carcinoma islater, compared to orbital metastasis from other malig-nancies (70.1 vs 53.6 years).4,5

Another differentiating feature is that prostate metasta-ses usually present as osteoblastic lesions in contrast to

Figure 4. Clinical photographs 2 weeks after radiotherapy. A,Reduced lid edema and partial ptosis of left eye. B, Reduced prop-tosis and resolved conjunctival chemotic congestion of left eye. C,Moderate restriction of elevation in left eye.

other orbital metastases which present as osteolyticlesions.4,5 However, in the terminal stages of the dis-ease, osteolytic and mixed osteoblatic-osteolytic lesionsare seen.6A characteristic feature suggestive of prostaticorigin is a hyperostotic and spiculated lesion on CTscan.7 Soft tissue involvement is rare and the PSA levelis elevated in 99% cases of metastatic disease.8,9 In con-trast to the aforementioned typical features, the presentcase was unusual because the patient presented withosteolytic metastasis to the orbit with significant soft tis-sue involvement and low PSA values, necessitating abiopsy to confirm the diagnosis.

Tumor metastasis to the orbit from prostate cancer mayoccur through the general hematogenous route of thecarotid/ophthalmic artery or through Batsons venousplexus, which transports tumor emboli from the prostateto the cerebral venous sinuses/ophthalmic vein.10–12

Patients usually present with one or more clinical fea-tures, such as decreased visual acuity, ocular pain, prop-tosis, retinal detachment, presence of a mass, secondaryglaucoma, and osteoblastic lesions of the orbital wall.12

The treatment of prostatic metastases to the orbit is pal-liative (androgen ablation or local radiotherapy) anddoes not alter survival.5

Prostate cancer is the second most common cancer inmen and the fifth most common cause of death fromcancer in men worldwide.13 Hence, clinicians shouldmaintain a high index of suspicion of metastasis fromprostate cancer in any elderly male who presents witheven a mild conjunctival chemosis. This is especiallyrelevant in patients with comorbid conditions that canlead to a similar clinical presentation. The present casehighlights the fact that neither the osteolytic nature ofthe orbitallesion nor normal PSA levels can conclusivelyrule out orbital lesions secondary to prostate carcinomaand that early and accurate diagnosis may only be possi-ble with a biopsy.

Literature ReviewPubmed, MEDLINE, Google Scholar, were all searched,without language restriction, on February 3, 2016, usingthe following terms: prostate carcinoma, orbital meta-stasis in prostate carcinoma, proptosis in orbital meta-stasis, PSA levels, vertebral veins AND prostate carci-noma.

References1. Carrierre VM, Karcioglu ZA, Apple DJ, Insler MS. A case of pros-

tate carcinoma with bilateral orbital metastases and the review of theliterature. Ophthalmology 1982;89:402-6.

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2. Sher JH, Weinstock SJ. Orbital metastasis of prostatic carcinoma.Can J Ophthalmol 1983;18:248-50.

3. Wolter JR, Hendrix RC. Osteoblastic prostate carcinoma to theorbit. Am J Ophthalmol 1981;91:648-51.

4. Boldt HC, Nerad JA. Orbital metastases from prostate carcinoma.Arch Ophthal 1988;106:1403-8.

5. Patel AR, Olson KB, Pienta KJ. Proptosis and decreased vision sec-ondary to prostate cancer orbital wall metastasis. Anticancer Res2005;25:3521-2.

6. Plesnicar S. The course of metastatic disease originating from carci-noma of the prostate. Clin Exp Metastasis 1985;3:103-10.

7. Vilenski L, Potti A, Mehdi SA. Unusual tumors involving the headand neckregion: case 3, proptosis due to metastatic prostate cancer. JClin Oncol 2001;19:4177-9.

8. Nayyar R, Singh P, Panda S, Kashyap S, Gupta NP. Proptosis due to“isolated” soft tissue orbital metastasis of prostate carcinoma. IndianJ Cancer 2010;47:74-6.

9. Lee DK, Park JH, Kim JH, et al. Progression of prostate cancerdespite an extremely low serum level of prostate-specific antigen.Korean J Urol 2010;51:358-61.

10. Gandhi HA, Shah MK. An unusual case of orbital metastasis fromadenocarcinoma of prostate. Hospital Physician 2005;41:41-3.

11. Baltogiannis D, Kalogeropoulos C, Loachim E, Agnantis N, PsilasK, Giannakopoulos X. Orbital metastasis from prostate carcinoma.Urol Int 2003;70:219-22.

12. Batson OV. The function of vertebral veins and their role in thespread of metastasis. 1940. Clin Orthop Relat Res 1995;312:4-9.

13. Ferlay, J.; Soerjomataram, I.; Ervik, M., et al. GLOBOCAN 2012v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet] Lyon, France: International Agency forResearch on Cancer; 2013. Available at http://globocan.iarc.fr,accessed February 2016.

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A 73-year-old man with congestion and mild …tosis and resolved conjunctival chemotic congestion of left eye. C, Moderate restriction of elevation in left eye. other orbital metastases